Related Experiment Video
Updated: May 12, 2026
An Immunological Model for Heterotopic Heart and Cardiac Muscle Cell Transplantation in Rats
Published on: May 8, 2020
Insurance-Based Disparities in Cardiac Allograft Vasculopathy After Heart Transplantation Are Mediated by Care at
Sara Sakowitz1, Syed Shahyan Bakhtiyar2, Saad Mallick1
1Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, California.
Insights
Medicaid insurance is linked to a higher risk of cardiac allograft vasculopathy (CAV) and worse survival after heart transplantation, particularly at non-high-volume centers. This highlights the need for closer post-transplant monitoring for vulnerable patient groups.
Area of Science:
- Cardiology
- Transplantation Medicine
- Health Services Research
Background:
- Socioeconomic factors, including Medicaid insurance, are associated with poorer outcomes post-heart transplantation.
- The specific mechanisms linking Medicaid insurance to inferior survival and complications like cardiac allograft vasculopathy (CAV) require further investigation.
Purpose of the Study:
- To evaluate the association between Medicaid insurance and the development of cardiac allograft vasculopathy (CAV) in heart transplant recipients.
- To explore how this association may have changed over time, particularly in relation to the Affordable Care Act (ACA).
- To examine the influence of hospital volume on the relationship between Medicaid and CAV development.
Main Methods:
- Analysis of adult heart transplant recipients (2004-2022) from the Organ Procurement and Transplantation Network.
- Stratification of patients into Medicaid and Non-Medicaid insurance cohorts.
- Definition of CAV based on angiographic coronary disease; categorization of hospitals by volume (high vs. non-high).
- Comparison of outcomes in pre-ACA (2004-2013) and post-ACA (2014-2022) eras.
Main Results:
- Medicaid insurance was associated with a significantly increased likelihood of developing CAV within 5 years post-transplant (HR 1.08).
- This association appeared more pronounced in the post-ACA era and was particularly strong at non-high-volume centers.
- Medicaid recipients experienced significantly inferior patient survival (HR 1.31) and allograft survival (HR 1.29) at 5 years.
Conclusions:
- Medicaid-insured heart transplant recipients face a greater risk of CAV and poorer long-term survival.
- These findings underscore the importance of targeted follow-up and management strategies for socioeconomically disadvantaged populations post-transplantation.
Background:
Socioeconomic disadvantage and Medicaid insurance have been linked with inferior survival after heart transplantation, yet the contributing mechanisms remain to be elucidated. We evaluated the association of Medicaid with the development of cardiac allograft vasculopathy (CAV).
Methods:
We considered heart transplant recipients aged ≥18 years within the 2004-2022 Organ Procurement and Transplantation Network. CAV was defined as any evidence of angiographic coronary disease. Institutional volume was computed, with hospitals in the highest quartile (≥19 cases/y) categorized as high-volume centers. Patients were stratified by insurance into the Medicaid and Non-Medicaid cohorts. The study period was divided into the pre-Affordable Care Act (ACA; 2004-2013) and post-ACA eras (2014-2022).
Results:
Of 37,073 heart transplant recipients, 4875 (13%) were insured by Medicaid. The overall incidence of CAV was 31%. After risk-adjustment, Medicaid insurance was linked with significantly greater likelihood of developing CAV over 5 years (Hazard Ratio [HR], 1.08, 95% CI, 1.01-1.16). Importantly, this effect seems to have emerged in the post-ACA era (Pre-ACA HR, 1.07, 95% CI 0.84-1.36; Post-ACA HR, 1.11, 95% CI, 1.02-1.21). Furthermore, among patients at high-volume centers, Medicaid insurance was linked with similar CAV likelihood (HR, 1.04, 95% CI, 0.95-1.14). Yet, considering those treated at non-high-volume centers, Medicaid was associated with significantly greater CAV hazard (HR, 1.14, 95% CI, 1.03-1.26). Overall, Medicaid remained associated with inferior patient (HR, 1.31, 95% CI, 1.21-1.42) and allograft survival at 5 years (HR, 1.29, 95% CI, 1.19-1.39).
Conclusions:
Medicaid-insured recipients faced inferior survival and greater risk of CAV over 5 years. Our work encourages closer follow-up and treatment for vulnerable populations in the months and years post-transplantation.
